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Post traumatic stress_disorder

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  • 1. Epilepsy & Behavior 19 (2010) 652–655 Contents lists available at ScienceDirect Epilepsy & Behavior j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / ye b e hCase ReportPosttraumatic stress disorder caused by the misattribution of seizure-relatedexperiential responsesMatthew L. Cohen a,⁎, Ronald H. Rozensky a, Zvinka Z. Zlatar a, Robert N. Averbuch b, Jean E. Cibula ca Department of Clinical and Health Psychology, University of Florida, Gainesville, FL, USAb Department of Psychiatry, University of Florida, Gainesville, FL, USAc Department of Neurology, University of Florida, Gainesville, FL, USAa r t i c l e i n f o a b s t r a c tArticle history: Patients with temporal lobe seizures sometimes experience what John Hughlings Jackson described asReceived 15 September 2010 “dreamy states” during seizure onset. These phenomena may be characterized by a re-experiencing of pastRevised 21 September 2010 events, feelings of familiarity (déjà vu), and hallucinations. In previous reports, patients have been aware of theAccepted 23 September 2010 illusory nature of their experiences. Here, however, the case of a patient with a documented 37-year history ofAvailable online 28 October 2010 temporal lobe epilepsy who is not aware is described. Fifteen years ago, the patient saw visions of traumatic autobiographical events that he had never previously recalled. He believed them to be veridical memories fromKeywords:Temporal lobe epilepsy his childhood, although evidence from his family suggests that they were not. The patients psychologicalSeizure reaction to the “recovery” of these traumatic “memories” was severe enough to qualify as posttraumatic stressExperiential phenomena disorder (PTSD). To our knowledge, this is the first report of PTSD caused by the misattribution of mental statesExperiential responses that accompany a seizure.Posttraumatic stress disorder © 2010 Elsevier Inc. All rights reserved.1. Introduction or intrusive recall of a past event; (2) there is a feeling of familiarity or reminiscence (i.e., déjà vu); (3) a sensation of dreaminess is In 1880, Hughlings Jackson reported on the presentation of characteristic; (4) the patient is said to be always aware of thefeelings of reminiscence and “dreamy states” that can occur at the incongruous and illusory nature of the experience; (5) affective statesonset of seizures [1]. These feelings have been described by patients as such as fear, sadness, guilt, anger, and sexual excitement are common;“dreamy feelings,” “dreams mixing with present thoughts,” “double (6) these responses typically lack certain features such as forwardconsciousness,” “feeling of being elsewhere,” and “as if I went back to motion in time. Sometimes, these experiences can be quite elaborate.all that occurred in my childhood.” One patient recalled, “I feel as if all Patient R.W., reported by Penfield and Perot [2], described fragmentsmust be a dream, though well knowing at the same time it must be of (what the authors interpreted to be) a fantasy or dream. Thereality … through it all the fear of some impending catastrophe seems authors described the patients responses on surgical stimulation of ato be hanging over me” (p. 202). Psychical seizures, as they were portion of the right temporal–parietal–occipital junction:called, often involve a sudden re-experiencing of the past or a suddenfalse interpretation of the present [2]. Today, these experiences are “Oh gosh! There [the robbers] are, my brother is there. He isgiven many names depending on the sensory modality in which they aiming an air rifle at me.” His eye moved slowly to the left. Thepresent (e.g., visual, auditory) and the type of experience [3,4]. In the figures seemed to disappear before the cessation of the stimulus.current discussion we use the term experiential response to refer to When asked, he said his brother was walking toward him, and thethis phenomenon because it is the most commonly used and least gun was loaded. When asked where he was, he said at his house,specific. in the yard. His other little brother was there, that was all. When Since the time of Hughlings Jackson, many accounts of these asked if he felt scared when he saw his brother, he said “Yes.”phenomena have been reported, and evidence from surgical stimula- When asked if he always felt scared when he saw the robbers, hetions and physiological recordings has provided insight, though not said, “Yes.” [2, p. 617]consensus, into the underlying processes [5]. Gloor [6] described themain features of these experiential responses: (1) there may be a vivid Although not described in the account by these authors, it is reasonable to believe that the patients recollection of his brother and the yard was veridical and that the situation with the robbers and the ⁎ Corresponding author. Department of Clinical and Health Psychology, College ofPublic Health and Health Professions, University of Florida, P.O. Box 100165, impending assault was fictitious. This type of confabulation of fact andGainesville, FL 32610-0165, USA. Fax: + 1 352 273 6156. fiction is what we believe we observed in the patient described in this E-mail address: mlcohen@phhp.ufl.edu (M.L. Cohen). report.1525-5050/$ – see front matter © 2010 Elsevier Inc. All rights reserved.doi:10.1016/j.yebeh.2010.09.029
  • 2. M.L. Cohen et al. / Epilepsy & Behavior 19 (2010) 652–655 6532. Case report Clinical interviews with Mr. F and his wife suggest that our patient experienced a detailed remembrance of what he believes to have been Mr. F (an arbitrary pseudonym) was recently referred to our psy- traumatic autobiographical experiences. However, evidence from hischology clinic by his attending psychiatrist for evaluation and treatment family suggests that these were not veridical memories, but ratherof symptoms of severe anxiety and depression. experiential responses that occurred at the onset of his temporal lobe Mr. F is a 55-year-old right-handed Caucasian man with 13 years of seizures, as have been described by Hughlings Jackson and others.formal education who was diagnosed with epilepsy in his early Mr. Fs experiences are coherent with the description provided byadulthood. He suffered a head trauma with loss of consciousness while Gloor [6], except that Mr. F does not perceive the incongruous anda high school student, and had no prior history of meningitis, illusory nature of his experiences and he is, instead, insistent thatencephalitis, or febrile convulsions. By his report, his first seizure these events occurred, noting the vivid details of the experiences. Hisoccurred when he was 17 years old. His developmental history is misinterpretation of these seizure-related experiences as veridical,unremarkable. There is no known family history of epilepsy. His mother traumatic memories directly contributes to his present-day psycho-died 24 hours after his delivery, reportedly as a result of a blood clot. He logical distress.reported having had a cyst removed from his left temporal lobe 1 year During his assessment, Mr. F spoke freely about these memories,after his seizure onset, although other historical documents suggest it although they were clearly distressing for him. Mr. F agreed, and iswas a bone cyst and subsequently grafted. The CT scan is not consistent presently in psychotherapy, to discuss the impact of these memories.with a craniotomy. Medical records are not available from that time to Because of his strong emotional reaction to these memories and theconfirm the details of his report. He has suffered multiple injuries strength of his focus on them, there was a possibility that prematurelybecause of his seizures, including rib fractures. addressing the falsehood of these memories might result in his At the time of his initial presentation to our hospital in 2008, he terminating therapy. Unfortunately, Mr. Fs tendency to deny thewas experiencing seizures twice weekly. A witnessed seizure in our impact of refractory epilepsy on his quality of life results in hispsychiatric hospital (where he had been hospitalized for depression focusing on these experiences rather than addressing day-to-dayand overdosing on phenytoin and diazepam) was described as psychosocial functioning related to managing his epilepsy and hisgeneralized shaking. He had no recall of this event, but could answer reactions to his actual limitations because of that diagnosis. He hasorientation questions during a subsequent complex partial seizure in discontinued follow-up with his neurologist and does not wish tothe emergency room. The only significant findings on his neurological undergo further evaluation (e.g., for epilepsy surgery) at this time.examination were an extensor plantar response on the left and Mr. F first recalled these traumatic childhood events 15 years agoatrophy of the muscles in the left C5 distribution. A CT scan of the head when his wife purchased a pocket watch for him which, he notes,showed a small cyst in the mesial right temporal structures, most “triggered repressed memories.” Interviewed separately, his wife saidconsistent with a choroidal fissure cyst (Fig. 1). His B12 level was that he did receive the watch a few weeks prior to the first recollection325 pg/mL; remaining labs were within normal limits except for an of the “memories,” but it was also precisely a week after experiencingalkaline phosphatase of 177 U/L (likely a result of chronic adminis- a particularly dramatic seizure, during which he fell and hit histration of phenytoin). An EEG obtained the next day revealed forehead on cement. Medical attention was not sought at that time;bitemporal interictal spikes, more frequent on the right than the thus, no medical records of this event or of any resulting injury orleft. Nine years previously, his EEG had shown only right temporal follow-up are available. Mrs. F remembered that when Mr. F firstspikes. Mr. F has refused MRI and video/EEG monitoring. Previously reported his recollection of the events a week after his seizure andtried medications also included phenobarbital, carbamazepine, and fall, he was “upset and confused” and has since continued to havegabapentin. After this hospital visit in 2008, he was changed from intrusive recollections of the events and often insists on discussingphenytoin to valproic acid. them with family who routinely tell him they have no recollection of the events. With the approval of our institutional review board, privacy office, and medical ethics lawyer, we describe his memories, but in a sufficiently vague manner so as to preserve his anonymity. The first recalled “memory” was estimated to have taken place when he was 4 or 5 years old, and comprised a series of related fragments involving hunting excursions in places actually frequented by his extended family in the southern United States. Prominent figures from then- contemporary American history participated in these hunts. During one incident, he “recalled” being frightened when one of these prominent U.S. historical figures stood up in a small boat with a shotgun, shot haphazardly, and rocked the boat. Later that same day, the same person impulsively shot their familys prized farm animal, causing much turmoil in the family. Mr. F described that when he first recalled this memory 15 years ago, his brother “didnt know what I was talking about,” and denied the incident had occurred. Interest- ingly, our own searches of historical literature indicated that these prominent figures were indeed visitors at these same locations at approximately the time Mr. F. actually had visited these places with his family. Mr. F may have known of these public figures frequenting the same vacation sites as his family and, as part of his experiential response, melded his autobiographical memories with his factual knowledge of the public figures’ visits. Multiple family members agree these events did not occur as Mr. F. recalls them. The second of his recovered memories was presented as signifi-Fig. 1. A CT scan of the head showed a small cyst in the mesial right temporal structures, cantly more traumatic. In this memory, Mr. F was approximatelymost consistent with a choroidal fissure cyst. 17 years old when a member of his rural community attempted to kill
  • 3. 654 M.L. Cohen et al. / Epilepsy & Behavior 19 (2010) 652–655him in a “ritualistic” fashion with the encouragement of Mr. F.s father. ment of spatially distant networks [6] and deep limbic structures. ItAt the last possible second, before he was “sacrificed,” his church has been shown, for example, that repeated seizures or stimulationpastor came to rescue him. Mr. F recalled specific phrases from the of a single cortical area, even within the same patient, can produceritual, but his recall of the events did not coalesce the way most different responses, whereas stimulation of widely distinct areasveridical memories do; they were fragmented and lacked sequential within the same individual can produce similar phenomena [8].order. Mr. F reported that there was no police report or arrest in thiscase. When asked why he thought the pocket watch was important in 3. Discussionunlocking these “repressed memories,” Mr. F said that it was the samewatch worn by the man who tried to ritualistically kill him. Mr. Fs wife To our knowledge, this is the first report of a patient not beingreported that she had discussed the story with Mr. Fs family members, aware of the illusory nature of an experiential response thatbut they did not recall any such event or threat to Mr. F. when he was a accompanied a seizure, thus producing a false memory. Furthermore,teenager. Mrs. F reported that her husband has experienced recurrent Mr. Fs experience is the first to demonstrate the magnitude ofsymptoms of depression throughout their marriage, and this has impairment that can result from such a misattribution. Mr. Fsadded to his poor quality of life along with the impact of his epilepsy. experience is also unique because a particular seizure (accompaniedShe reported that in the 15 years following the fall and the recovery of by probable concussion) “unlocked” these memories, which werethese memories, his depression has progressively worsened and led subsequently identified by Mr. F as having taken place at highlyhim to attempt suicide several times in the past few years by specific times and specific places in his life, a process that includes theoverdosing on anticonvulsant medication. Prior to that, both Mrs. F integration of real and fictitious places, people, and events.and his wife note that he had had no significant history of The influence of Mr. Fs probable concussion cannot be knownpsychological problems or a history of psychological or psychiatric definitively. If Mr. F sustained frontal lobe damage during the seizurediagnoses or treatment in his childhood, adolescence, or adulthood. in question, it is unlikely that this damage alone could cause thePresently, Mr. Fs seizure activity is unpredictable, varying in occur- creation and then misattribution of autobiographical visions, and werence from once every 3 weeks to two to three times per week. His have not found reports of this in the literature. If frontal lobe damagewife reported that at the onset of a seizure, Mr. F will occasionally say was sustained, a more likely possibility is that the temporal lobethat someone is hurting him and will command that person to stop. seizure produced the vision, and co-occurring frontal lobe damageWe have hypothesized that this may be a recurrence of his traumatic resulted in Mr. Fs inability to correctly connect the vision to itsvision of being prepared for execution. Since the recovery of correct source (i.e., the seizure) and context (i.e., not in histhese memories, Mr. F reported recurrent, intrusive, and distressing childhood). This possibility is more consistent with previous reportsthoughts involving these events. He continues to discuss the content of of temporal lobe seizures [2,4,6] and the role of the frontal lobes inthese memories with various family members, who are frustrated and source memory [9].distressed by his inability to accept that these events did not occur. It is possible that these memories are so intrusive and persistent in Mr. Fs psychological reaction to these memories/occurrences nature because they are re-experienced at the onset of his seizures (asmeets DSM-IV-TR criteria for Posttraumatic Stress Disorder (PTSD) suggested by his wifes account) and are thus reinforced by frequent[7]. Mr. F experienced an event, albeit of questionable veridicality, neural activity. Additionally, it is possible that, even though thebut perceived by the patient to be real, involving threatened death, memories are traumatic, they may be easier for Mr. F to focus on thanand his response involved intense fear, helplessness, and horror the day-to-day psychological and social struggles he has managing an(criterion A). Furthermore, he experiences recurrent and intrusive unpredictable course of epilepsy.recollections of the ritual, as well as psychological and physiological Our experience working with Mr. F illustrates several importantreactivity to internal and external cues that symbolize and resemble points that extend beyond the idiosyncrasies of his particularthe event (criterion B). Mr. F attempts to avoid activities, places, and presentation. To properly diagnose and plan treatment for patientspeople that arouse recollections of the trauma, experiences a feeling with complicated and multifaceted difficulties, the practitioner mustof detachment from others, demonstrates a restricted range of affect have broad knowledge of the range of problems and diagnoses(criterion C), and reports difficulty falling asleep and concentrating involved and the skills and competencies required to work with the(criterion D). These symptoms have endured for more than 1 month complex problems presented [10,11]. Furthermore, close communi-(criterion E) and cause significant distress and impairment in social cation between disciplines should be emphasized. Without carefulfunctioning (criterion F). Indeed, his frequent discussions of the assessment and consideration of all variables, this patient may haveevents with family members have caused significant strain in his been prematurely diagnosed only with Major Depressive Disorder orrelationships with the people to whom he recounts the stories Posttraumatic Stress Disorder or only with temporal lobe epilepsy,repeatedly. There is no evidence to suggest that Mr. Fs experience missing the complicated tension between these disorders.would be better described and explained by another diagnosis, such as Additionally, because of complexities in the reporting of this case,psychotic depression, and as reported, has had no history of delusions, such as the de-identification of Mr. Fs unique memories, we consultedhallucinations, or other psychotic-like symptoms or history. His multiple sources to ethically report his case. Our institutional reviewresponses are circumscribed to reactions to the specific memories in board agreed that the proceedings described here officially constitutequestion; he exhibits no other current delusions or hallucinations. a case study and therefore do not require an institutional reviewFurthermore, although his presentation may have initially been board-approved protocol. Our institutions privacy office and medicalclassified as Adjustment Disorder with Depressed Mood, he now ethics lawyer were consulted to ensure our due diligence in protectingqualifies for Major Depressive Disorder, Recurrent, along with Mr. Fs interests. Mr. F provided formal written agreement to thePosttraumatic Stress Disorder. writing and dissemination of this article. It should be noted that our Despite our strong recommendation, Mr. F declined our referral for obligation to protect his anonymity (despite his unique and perhapsa more current neurological evaluation, neuroimaging, and neuro- identifiable memories), as well as a clinical responsibility to protectpsychological evaluation. His most recent EEG appeared to demon- him from premature confrontation of the non-veridicality of hisstrate more extensive involvement (now bitemporal) than previously. memories, complicated our ability to report this case. We recommendAlthough routine interictal scalp EEG data are limited in their that others wishing to report on such clinically sensitive cases seeksensitivity and specificity, ictal EEG data might be more conclusive, consultation from all available sources, such as ethics boards,but are unavailable. Furthermore, attempts to localize these occur- institutional review boards, and privacy offices, as this was helpfulrences to circumscribed regions may fail to appreciate the involve- to us.
  • 4. M.L. Cohen et al. / Epilepsy & Behavior 19 (2010) 652–655 655Acknowledgments [4] Vignal JP, Maillard L, McGonigal A, Chauvel P. The dreamy state: hallucinations of autobiographic memory evoked by temporal lobe stimulations and seizures. Brain 2007;130:88–99. We thank Mr. F for his candor and willingness to share his story [5] Elliott B, Joyce E, Shorvon S. Delusions, illusions and hallucinations in epilepsy: 1.with the psychological and medical communities. We also thank Elementary phenomena. Epilepsy Res 2009;85:162–71. [6] Gloor P. Experiential phenomena of temporal lobe epilepsy: facts and hypotheses.William Allen for his helpful comments and suggestions. Brain 1990;113:1673–94. [7] Diagnostic and statistical manual of mental disorders. 4th ed. text rev. Washington, DC: American Psychiatric Assoc; 2000.References [8] Horowitz MJ, Adams JE, Rutkins BB. Visual imagery on brain stimulation. Arch Gen Psychiatry 1968;19:469–86.[1] Jackson JH. On right or left sided spasm at the onset of epileptic paroxyms, and on [9] Janowsky JS, Shimamura AP, Squire LR. Source memory impairment in patients crude sensation warnings, and elaborate mental states. Brain 1880;2:192–206. with frontal lobe lesions. Neuropsychologia 1989;27:1043–56.[2] Penfield W, Perot P. The brains record of auditory and visual experience: a final [10] Belar CD, Brown RA, Hersch LE, et al. Self-assessment in clinical health summary and discussion. Brain 1963;86:595–696. psychology: a model for ethical expansion of practice. Prof Psychol Res Pr[3] Barbeau E, Wendling F, Regis J, et al. Recollection of vivid memories after 2001;32:135–41. perirhinal region stimulations: synchronization in the theta range of spatially [11] France CR, Masters KS, Belar CD, et al. Application of the competency model to distributed brain areas. Neuropsychologia 2005;43:1329–37. clinical health psychology. Prof Psychol Res Pr 2008;39:573–80.

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